Childbirth-Related Psychological Trauma: It’s Finally on the Radar and It Affects Breastfeeding

I first became interested in childbirth-related psychological trauma in 1990. Twenty-three years ago, it was not something researchers were interested in studying. I found only one study, and it reported that there was no relation between women’s birth experiences and their emotional health. Those results never rang true for me. There were just too many stories floating around with women describing their harrowing births. I was convinced that the researchers got it wrong,

To really understand this issue, I decided to immerse myself in the literature on posttraumatic stress disorder (PTSD). During the 1980s and 1990s, most trauma researchers were interested in the effects of combat, the Holocaust, or sexual assault. Not birth. But in Charles Figley’s classic book, Trauma and Its Wake, Vol. 2 (1986), I stumbled upon something that was quite helpful in understanding the possible impact of birth. In summarizing the state of trauma research in the mid-1980s, Charles stated that an event will be troubling to the extent that it is “sudden, dangerous, and overwhelming.” That was a perfect framework for me to begin to understand women’s experiences of birth. It focused on women’s subjective reactions, and I used it to describe birth trauma in my first book, Postpartum depression (1992, Sage).

Since writing Postpartum Depression, there has been an explosion of excellent research on the subject of birth trauma. The bad news is that what these researchers are finding is quite distressing: high numbers of American women, as well as women in other countries, have posttraumatic stress symptoms (PTS) after birth. Some even meet full criteria for posttraumatic stress disorder. For example, Childbirth Connection’s Listening to Mothers’ Survey II included a nationally representative sample of 1,573 mothers. They found that 9% met full-criteria for posttraumatic stress disorder following their births, and an additional 18% had posttraumatic symptoms (Beck, Gable, Sakala, & Declercq, 2011). These findings also varied by ethnic group: a whopping 26% of non-Hispanic black mothers had PTS. The authors noted that “the high percentage of mothers with elevated posttraumatic stress symptoms is a sobering statistic” (Beck, et al., 2011).

If the number of women meeting full-criteria does not seem very high to you, I invite you to compare it to another number. In the weeks following September 11th, 7.5% of residents of lower Manhattan met full criteria for PTSD (Galea et al., 2003).

Take a minute to absorb these statistics. In at least one large study, the rates of full-criteria PTSD in the U.S. following childbirth are now higher than those following a major terrorist attack.

In a meta-ethnography of 10 studies, women with PTSD were more likely to describe their births negatively if they felt “invisible and out of control” (Elmir, Schmied, Wilkes, & Jackson, 2010). The women used phrases, such as “barbaric,” “inhumane,” “intrusive,” “horrific,” and “degrading” to describe the mistreatment they received from healthcare professionals.

“Isn’t that just birth?,” you might ask. “Birth is hard.” Yes, it certainly can be.

But see what happens to these rates in countries where birth is treated as a normal event, where there are fewer interventions, and where women have continuous labor support. For example, in a prospective study from Sweden (N=1,224), 1.3% of mothers had PTSD and 9% described their births as traumatic (Soderquist, Wijma, Thorbert, & Wijma, 2009). Similarly, a study of 907 women in the Netherlands found that 1.2% had PTSD and 9% identified their births as traumatic (Stramrood et al., 2011). Both of the countries reported considerably lower rates of PTS and PTSD than those found in the U.S.

How Does this Influence Breastfeeding?

Breastfeeding can be adversely impacted by traumatic birth experiences, as these mothers in Beck and Watson’s study (Beck & Watson, 2008) describe:

I hated breastfeeding because it hurt to try and sit to do it. I couldn’t seem to manage lying down. I was cheated out of breastfeeding. I feel that I have been cheated out of something exceptional.

The first five months of my baby’s life (before I got help) are a virtual blank. I dutifully nursed him every two to three hours on demand, but I rarely made eye contact with him and dumped him in his crib as soon as I was done. I thought that if it were not for breastfeeding, I could go the whole day without interacting with him at all.

Breastfeeding can also be enormously healing, and with gentle assistance can work even after the most difficult births.

Breastfeeding became my focus for overcoming the birth and proving to everyone else, and mostly to me, that there was something that I could do right. It was part of my crusade, so to speak, to prove myself as a mother.

My body’s ability to produce milk, and so the sustenance to keep my baby alive, also helped to restore my faith in my body, which at some core level, I felt had really let me down, due to a terrible pregnancy, labor, and birth. It helped build my confidence in my body and as a mother. It helped me heal and feel connected to my baby.

What You Can Do to Help

There are many things that nurses, doulas, childbirth educators, and lactation consultants can do to help mothers heal and have positive breastfeeding experiences in the wake of traumatic births. You really can make a difference for these mothers.

Recognize symptoms.

Although it is not within many of our scope of practice to diagnose PTSD, you can listen to a mother’s story. That, by itself, can be healing. If you believe she has PTS or PTSD, or other sequelae of trauma, such as depression or anxiety, you can refer her to specialists or provide information about resources that are available (see below). Trauma survivors often believe that they are going “crazy.” Knowing that posttraumatic symptoms are both predictable and quite treatable can reassure them.

The site HelpGuide.org also has many great resources including a summary of available treatments, lists of symptoms, and possible risk factors.

Anticipate possible breastfeeding problems mothers might encounter.

Severe stress during labor can delay lactogenesis II by as much as several days (Grajeda & Perez-Escamilla, 2002). Recognize that this can happen, and work with the mother to develop a plan to counter it. Some strategies for this include increasing skin-to-skin contact if she can tolerate it, and/or possibly beginning a pumping regimen until lactogenesis II has begun. She may also need to briefly supplement, but that will not be necessary in all cases.

Recognize that breastfeeding can be quite healing for trauma survivors, but also respect the mothers’ boundaries.

Some mothers may be too overwhelmed to initiate or continue breastfeeding. Sometimes, with gentle encouragement, a mother may be able handle it. But if she can’t, we must respect that. Even if a mother decides not to breastfeed, we must gently encourage her to connect with her baby in other ways, such as skin to skin, babywearing or infant massage.

Partner with other groups and organizations who want to reform birth in the U.S.

Our rates of PTS and PTSD following birth are scandalously high. Organizations, such as Childbirth Connection, are working to reform birth in the U.S.

2013 may be a banner year for recognizing and responding to childbirth-related trauma. The new PTSD diagnostic criteria were released in May in the DSM-5, and more mothers may be identified as having PTS and PTSD.

There has also been a large upswing in U.S. in the number of hospitals starting the process to become Baby Friendly, which will encourage better birthing practices.

There is also a major push to among organizations, such as March of Dimes, to discourage high-intervention procedures, such as elective inductions.

And hospitals with high cesarean rates are under scrutiny. This could be the year when mothers are care providers stand together, and say that the high rate of traumatic birth is not acceptable, and it’s time that we do something about it. Amy Romano describes it this way.

As we begin 2013, it is clear from my vantage point at the Transforming Maternity Care Partnership that the transformation is underway. In Childbirth Connection’s nearly century-long history, we’ve never seen so much political will from leaders, so much passion from grassroots advocates, and so much collaboration among clinicians and other stakeholders. This new landscape presents many new opportunities for educators and advocates.

There is much you can do to help mothers who have experienced birth-related trauma. Whether you join the effort to advocate for all mothers, or simply help one traumatized mother at a time, you are making a difference. Thank you for all you do for babies and new mothers.

This article originally appeared as an editorial in the journal Clinical Lactation: Kendall-Tackett, K.A. (2013). Childbirth-related psychological trauma: An issue whose time has come. Clinical Lactation, 4(1), 9-11

Kathleen Kendall-Tackett is a health psychologist and an International Board Certified Lactation Consultant. She is the Owner and Editor-in-Chief of Praeclarus Press, a small press specializing in women’s health. Dr. Kendall-Tackett is a Fellow of the American Psychological Association in both the Divisions of Health and Trauma Psychology, Editor-in-Chief of U.S. Lactation Consultant Association’s journal, Clinical Lactation, and is President-Elect of the American Psychological Association’s Division of Trauma Psychology. Dr. Kendall-Tackett is author of more than 320 journal articles, book chapters and other publications, and author or editor of 22 books in the fields of trauma, women’s health, depression, and breastfeeding, including Treating the Lifetime Health Effects of Childhood Victimization, 2nd Edition (2013, Civic Research Institute), Depression in New Mothers, 2nd Edition (2010, Routledge), and Breastfeeding Made Simple, 2nd Edition (co-authored with Nancy Mohrbacher, 2010).

One way to lessen the risk of medical trauma in birth is to deliver at home with a qualified attendant (such as a midwife or physician with home-birth experience), with a plan in place for hospital transfer should that become necessary. There is a great deal of comfort in being in a familiar environment with supportive people in attendance (who are not people that you first met in labor because they were on shift at the hospital). A home setting goes a long way to avoiding “sudden, dangerous, and overwhelming.”

Great article. Love the song! My thirty years experience of working with healing birth trauma confirms the points made.
It is fundamental to good health for mother and babies that Birth be undisturbed and the integrity of the organism be supported. Health mothers and babies are the foundation of a strong community on every level. It’s bad economics to compromise birth.

Dear Kathleen,
Thanks for your great article highlighting the traumatic effects of child birth. I am a physiotherapist from Australia and want to inform you about TRE which deliberately invokes neurogenic tremors to release the effects of trauma. As you would be aware, the majority of women experience these spontaneous tremors during or after child birth. Few birth educators know the full extent and vital role these tremors play in trauma recovery. Not only could further education about their role and purpose help birth workers support or even facilitate them, there is also a simple way for post birth women to invoke them themselves. As these tremors re-regulate the nervous system and are often naturally occuring, their facilitation or even deliberate use has huge potential to affect immediate birth recovery, let down and breastfeed and perhaps most critically bonding and attachment by allowing the mother to return more quickly to a baseline state. I would love to send you more information including my workshop flyer entitled ‘Debriefing the body after birth’ and would be happy to put you in touch with TRE founder Dr David Berceli who is US based. The potential value of the deliberate use of these tremors during and after birth offers a huge opportunity to assist women to recover and best of all is self-empowering as it doesn’t require a therapist or external intervention. On top of that the tremors can be used on an ongoing basis to not only recover from birth, but to release the tension and stress of early parenting and also to unwind past unresolved trauma still held in the body. Would love to hear back from you or to skype as I am sure you would find this really valuable information and highly pertinent to assist birthing mothers. Regards, Richmond

Hi Kathleen thanks so much for this informative, scholarly article. I love that you included the rates of PTSD/PTS (onset childbirth) in the US, where high intervention childbirth is the “accepted” model to the European rate, where the midwifery model of care is accepted model. I work with NJ BirthNetwork, a chapter of the CIMS, and we are all working towards providing more humane care for women and families around the childbirth year. I also love how you blended information about breastfeeding into this article. Yes, many women find breastfeeding to be an emotionally healing experience and others don’t. It depends on the individual and the situation, and clinicians and support persons need to respect what is possible and what is wanted. Thanks for this to add to the conversation! Namaste, Kathy

Hi Kathleen – I just wanted to add something that’s niggling at me about the stats on PTSD and 9/11. It just doesn’t feel right to me. I havent read the study, but it sounds way low. I live in the NYC area and practice psychotherapy. I have quite a few clients coming in who have PSTD symptoms from the events at 9/11; many first responders live around in the suburbs here who went in to assist at 9/11…just some thoughts, thanks, Kathy

Hi Kathleen, great to see the emergence of research into this area. I have been waiting for this as well and was surprised at the absence and the inconclusivity of the research to date. I think we also need to remember the impact of PTSD on the baby. Mother and child are so connected or striving for connection that it is inevitable the baby will be impacted. These impacts are life long and become deeply entrenched patterns of being. Raising awareness of these issues can only assist professionals respond holistically and collaboratively to the dyad. Kate.

Arthur Janov (Primal Therapy) wrote a book on this subject back in the early eighties – “Imprints, The Lifelong Effects of the Birth Experience”. Frederick Leboyer also advocated a gentle birth environment in his 1975 book “Birth Without Violence”. Decades ago, there was more information on this subject than one might think, but it was considered rather fringe psychology back then (nice to see it gaining some credibility). I’d also like to agree with Richmond Heath (who posted above) about TRE – a very powerful way to recover from trauma. I use it myself.